Molina Medicaid Solutions - DHHR

Bridging the Rivers ofChange TogetherWest Virginia MMIS Re-ProcurementSolicitation: MED130063. Operations Management (OM)OM1. Service AuthorizationYESwithoutReq #Description of RequirementcustomizationOM1.49 Ability to accept and retain the PA number submitted by the PA Xvendor.OM1.50 Ability to use tracking number to link attachments submitted by Xmail to electronic PA request.OM1.51 Ability to use tracking number to link attachments submittedXelectronically to electronic PA request.OM1.52 Ability to recognize both the NPI and former Medicaid ID number. XOM1.53 The system should have the ability to capture and display PA data Xwhich includes, at minimum, the following:OM1.54 PA number XOM1.55 Member ID XOM1.56 Service code/s XOM1.57 Procedure/NDC code XOM1.58 Modifier codes XOM1.59 Billing, rendering, and referring Provider information,Xincluding name, and Provider ID/NPIOM1.60 Dates of service XOM1.61 Effective and term date of PA XOM1.62 Requested effective date of PA XOM1.63 Units of service expressed as days, quantity per day, number of Xservices, dollars, tooth number/letter, tooth surfaceOM1.64 Quantity used XOM1.65 Miscellaneous codes w/ notes field (for contractors) XOM1.66 Rates XOM1.67 Member Rate code XOM1.68 Dollar cap XOM1.69 Local Provider information XOM1.70 Limits (including calendar month limits) XOM1.71 Room and board XOM1.72 Waiver start date XOM1.73 Manufacturer product number XOM1.74 Status of the PA request (including pending, denied, approved, Xand modified)OM1.75 Date approved XOM1.76 History of all actions taken on PA request, includingXamendmentsOM1.77 Date of last change, ID of person changing, and information Xchanged for each PA recordOM1.78 ID of authorizing person XOM1.79 Other as identified by BMS during DDI and accepted viaXformal change controlOM1.80 Ability to allow the identification of the principal procedure and Xdate, and the inclusion of five additional procedures and dates.OM1.81 Ability to include descriptions of codes in the PA request. XOM1.82 Ability to allow for expansion and addition of fields to the on-line XPA request form.OM1.83 Ability to provide a free-form text narrative (length to be approved Xby BMS) at the base PA level and at functional levels that:YESwithcustomizationNOunable toprovide14.2-23